National Policy on Injection Safety and Healthcare Waste management 2007

ABBREVIATIONS/ ACRONYMS
AD Auto- disables (syringes)
AIDS Acquired Immune Deficiency Syndrome
BASICS Basic Support for Institutionalizing Child Survival
BCC Behaviour Change Communication
CBO Community Based Organization
CMD Chief Medical Director
EPI Expanded Programme on Immunization
ESA External Support Agency
FCT Federal Capital Territory
FGD Focus Group Discussion
FMOH Federal Ministry of Health
GON Government of Nigeria
HBV Hepatitis B virus

HCV Hepatitis C virus
HIV Human Immunodeficiency Virus
IS Injection Safety
JSI John Snow Incorporated
KAP Knowledge, Attitude and Programme
MD Medical Director
LGA Local Government Area
MMIS Making Medical Injection Safer
NACA National Action Committee AIDS
NASCP National AIDS and STI Control Programme
PEPEAR President’s Emergency Plan for AIDS Relief
SIGN Safe Injection Global Network
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WHO world Health Organization.

1.0 BACKGROUND

1.1. PREAMBLE
The national Policy on Injection Safety and Health Care waste Management sets out to ensure that patients, health workers, communities and the environment are protected from risks associated with unnecessary and unsafe injections, as well as improper treatment and disposal of injection materials and other health care waste. The policy document will achieve this objective by providing guiding principles for safe injection practices and proper management of all health care waste.

According to World Health Organization (WHO) standard for injection safety:
“Safe injection do not harm their recipients, do not expose the health care worker to any avoidable risk and do not result in waste that is dangerous to the community.”

The re-use of injection devices without proper sterilization, and exposure to contaminated sharps and waste increase the risk of transmission of blood-borne pathogens including hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV)
Nigeria does not have a policy that is particular to injection safety and health care waste management. What is on ground are policies such as the national immunization policy that has a chapter on injection safety with respect to immunization and a national policy on environmental and solid waste management master plan which touches on medical waste management.
Given these concerns, the Federal Ministry of Health through the National Injection Safety Forum conducted an assessment of injection practices and health care waste management practices in Nigeria. The with other government policy documents related to different aspects of injection safety and health care management were used to develop this policy.


1.2. SITUATION ANALYSIS
A national cross- sectional survey of injection safety practices in health facilities was conducted under the auspices of the National Injection Safety Forum between July and August 2004. The study indicated that most prominent factors contributing to unsafe injection practices include:
 Over- prescription of injections
 Limited availability of guidelines for health workers on injection safety practices including the care of needle stick injuries at all health care levels
 Inadequate supply of injection materials leading to reuse of injection supplies without sterilization
 Inadequate facilities for sterilization and
 Lack of adequate facilities for collection and disposal of injection wastes

The survey showed that over 55.1% of the survey respondents received more than one injection per year with a 4.9 injection per person per year burden, putting Nigeria among the group of countries in the sub-Saharan region with a poor to moderate use of wrong and unsafe injections.
The majority (99%) of surveyed health facilities reported to having experienced a shortage of disposable injection supplies in the 12 month prior to the survey. This was an issue particularly in the curative sector. This might be a reflection of the current less- than optimal logistics system (e.g. forecasting and distribution mechanisms). Furthermore, improper management of health care waste was observed in an estimated 65% of health facilities, which had used sharps present around the building. Bad injection safety practices were common, such as leaving the needle on ampoules in between injections 49.2% for therapeutic and 25.9% for immunization injections.

The finding of this survey are consistent with the results of previous surveys, which showed that children under five year received more than 10 injection per year.1 Furthermore it was found that 10%, 66.7% of household had to bring syringes for injection use in Lagos and Kano States as well as the Federal Capital Territory respectively2. Other studies confirm that the practices of indiscriminate dumping, burning and buying are prevalent in a significant number of health facilities. Incineration facilities are limited and where available, the absence of an adequate health policy addressing the safe use of injections and proper waste disposal.

2.0 MISSION STATEMENT
The mission of this policy is to protect and or minimize the risks due to unsafe injection and health care waste management practices to the patients, health workers, consumers and the environment from hazardous healthcare waste disposal practices.

2.1 OVERALL GOAL
This policy aims at ensuring safe injection practices and proper management of health care waste. This goal will be achieved through the appropriate procurement, distribution, monitoring of equipment/ supplies, improve injection and health care waste management practices and increased awareness.

2.2 OVERALL OBJECTIVE
To provide an enabling environment to ensure injection safety practices and appropriate management of health care waste.

2.3 GUIDING PRINCIPLES
 Behaviour of the patients, health workers and the community significantly affect injection and waste management practices.
 Appropriate procurement, distribution and monitoring of injection equipment and related supplies such as safety boxes, auto disable syringes and needle cutters.
 Minimal risks to patients, health workers, communities and the environment
 Capacity building for safe use of injection materials and appropriate healthcare waste management as well as supervision and monitoring of health facilities at all levels of implementation to ensure behavioral change.






3.0 COMMUNICATION AND BEHAVIOUR CHANGE
3.1 policy issue:
 There is irrational prescription of injections by health workers, partly caused by the demand from patients.
 There is a significant amount of risk of blood borne disease transmission such as Hepatitis B, Hepatitis C and HIV due to the re-use of disposable injection materials, including sharing of injection materials, families.
 There is indiscriminate dumping and disposal of health care waste in Health institutions, municipalities and communities.
3.2 Policy Objective:
 To eliminate the practice of re-using disposable needles and syringes, including sharing among family members.
 To provide guideline for health workers in both public and private sectors and communities for proper health care waste management disposal practice.


3.3 POLICY STRATEGIES:
 Implement effective behavioral change approaches to injection safety, targeting both health workers and communities through effective advocacy, community mobilization, communication, and creating an enabling environment.
 Training of health care workers in injection safety issues and appropriate waste disposal practices.
 Educate and encourage patients to seek treatment only from qualified providers.
 Support supervision of health care workers involved in administration of injections and the process of disposal and destruction of health care waste.
 Use of behavioral trials to model effective behavior change approaches for clients and health workers; to discourage unnecessary injections, reduce re-use of injection materials, discourage sharing injection materials among family members, and safety dispose waste immediately and destroy it within the week.

4.0 HEALTH CARE WASTE MANAGEMENT
4.1 Policy Issue:
There is inadequate health care waste management system for health care facilities and the communities.

4.2 Policy Objectives:
 To provide guidelines for injection and other health care waste management practices to all health facilities.
 To ensure that all health facilities have easy access to appropriate disposal facilities for used injections and other health care waste.
 To establish and ensure that proper injection and other health care waste management practice are observed at all health facilities and in the community.
 To mobilize the community on appropriate health care waste management.

4.3 POLICY STRATEGIES:
 Establish and implement a system for ensuring that injections and other health care waste are properly managed by persons and facilities generating them both in the health sector and in the communities.
 Develop and disseminate guidelines for injection and other health care waste management
 Construction and installation of injection and other health care waste disposal destruction facilities
 Safe collection and transportation of sharps, other injection materials and their disposal using incinerators or other environmentally approved means.

4.4 Targets
In order to ensure measurable benchmarks, monitor and evaluate the progress and implementation of this policy over time, the following targets to guide programme planning and implementation are set.
 The federal Ministry of health shall ensure the enactment of relevant legislations required for effective healthcare waste management policy implementation by 2008;
 By the end of 2008, every healthcare facility shall put in an infection control and waste management committee to include head of the hospital or his representation, the heads of departments in the hospital, the registered Environment Health Officer in charge of waste management in the hospital, etc.
 By the end of 2008, every Teaching Hospital, Specialist hospital and Federal Medical Centers and other similar health care facilities with more than 200 beds shall provide within their premises a modern incinerator which complies with World Health Organization standard on air pollution emission, capable of on-site destruction of all contaminated waste water are treated prior to disposal outside the facility.
 By the end of 2010, every Teaching Hospital, Specialist Hospital and Federal Medical Centres and other health care facilities with more than 200 beds shall provide within their premises a modern waste water treatment plant to ensure that all contaminated waste water are treated prior to disposal outside the facility.
 By the end of 2010, every other health care facility provider shall have a subsisting contract with a registered healthcare waste or sewage collector who also has a disposal contract with a disposal facility for the collection and final disposal of health care waste from such facilities.
4.5. Institutional Framework, Roles and Responsibilities
4.5.1 Federal Ministry of Health shall:
In collaboration with other line Ministries, ensure the implementation of this policy.
 Formulate, review and produce the National Policy on injection safety and Healthcare Waste Management;
 Enact, review and harmonize existing Legislation on injection safety and healthcare waste management;
 Develop and ensure the implementation of the National Action Plan on injection safety and healthcare waste management;
 Collaborate with the Academic, Research Institutions, other relevant Ministries, Agencies, ESAs, NGOs and the private sector on injection safety and healthcare waste management;
 Embark on capacity building and human resource development for managing injection safety and healthcare waste management;
 Mobilize resources both internally and externally for healthcare waste management
4.5.2. State: (Ministry of Health)
 Provide technical assistance and logistic support to LGA on the implementation of the National Policy on Injection Safety and Healthcare Waste Management;
 Encourage and support private sector participation in the implementation of the National Policy on injection Safety and healthcare Waste Management through legislation and provision of financial instrument;
4.5.3. LGA shall:
 Enact and enforce appropriate legislation on injection safety and healthcare waste management;
 Recruit or grant franchise within their area of jurisdiction to licensed Environmental Health Officers for effective inspection and enforcement of healthcare waste management plans;
4.5.4 HEALTH CARE FACILITIES
All healthcare facilities shall:
 Ensure segregation of wastes at every point of generation within the healthcare facility using the appropriate primary collection equipment with appropriate color coding.
 By 2008, provide a budget line with sufficient funds and appropriate manpower, dedicated to healthcare waste management in their facility.
 Provide facilities for the safe disposal of all hazardous healthcare waste produced from such facilities.
 With higher installed capacity for onside disposal of healthcare waste than they presently required, shall provide such excess capacity to other healthcare facilities in the area for the disposal of their own wastes at the reasonable cost,
4.5.5 Civil Society Organizations (NGOs/ CBOs) shall:
 Support the implementation on National Policy on injection Safety and Healthcare Waste Management ;
 Mobilize communities through awareness campaigns about National Policy on Injection Safety and Healthcare Waste management;
 Provide support in the development of IEC materials on National Policy on Injection Safety and Healthcare Waste Management ;
 Develop community programmes that will support implementation of National Policy on Injection and Healthcare Waste Management ;
 Educate communities on the National Policy on Injection Safety and Healthcare Waste Management ;
4.5.6 Organized Private Sector Shall:
 Support the implementation on National Policy on Injection Safety and Healthcare Waste Management ;
 Participate in the provision of Injection Safety and Healthcare Waste Management ;
 Support research in Injection Safety and Healthcare Waste Management;
4.5.7 Professional Regulatory Bodies and Academia shall;
 Revise training curricula to reflect training gap on injection safety and healthcare waste management issues;
 Conduct training and manpower development of their members on injection safety and healthcare waste management;
 Collaborate with Federal Ministry of Health in propagating information on injection safety and healthcare waste management research findings amongst their professional.

4.6 Funding Mechanisms

Investing in injection safety and healthcare waste management is expected to benefit not only the health system but equally promote employment and improve good quality of life. In order to attain the lofty goal of National Policy on injection safety and healthcare waste management, substantial financial and logistic resources are required. It is therefore, important that funding for this policy must be well thought out and sustainable to ensure that adequate funds required to sustain this policy in the long run are provided.
The government shall:
 Create a conducive environment for private sector participation;
 Increase private sector participation in healthcare waste management with reduced Government involvement through provision of loan facilities to registered healthcare waste management companies;
 Liaison with the Ministry of finance and other government financial institution to ensure that adequate funds are provided to registered healthcare waste management companies to assist in procurement of equipment and buildup infrastructure required for the effective implementation of the policy.
 The ultimate objective of the aim of the National policy on injection safety and healthcare waste management is to obtain self-sustaining facilities and services at all healthcare facilities. In order for the realization of the objectives of this policy, adequate emphasis shall be on sustainable fund generating mechanism. In this regard, financial and other resources for implementing the National policy on injection safety and healthcare waste management shall be obtained from :
 All tiers of Government through yearly budgetary allocations for infrastructural provision in their healthcare facilities;
 Funding from entrepreneurial/small-scale industries funds of the bankers committee.
 External Support Agencies;
 Organized private sectors;
 User charges;
 Capital market;
 Philanthropic Organizations;
 Fines and levies.

5.0 LOGISTICS

5.1 Policy Issues:
Logistics functions, among which are forecasting, selection, and distribution are inadequately addressed or given inadequate attention, which leads to shortages and stock-outs.

5.2 Policy Objectives:
 To ensure an adequate and continuous supply of injection equipments consumables and other medical supplies by establishing and maintaining a secure, cost-effective logistic system
 To ensure proper product selection (auto- disable syringes for preventive services)
 To ensure that matching quantities of syringes and needles are ordered with drug and vaccine supplies
 To ensure safe, efficient and effective disposal of a healthcare waste using incinerators or other approved identified means.

5.3 policy Strategies:
 Appropriate, adequate and safe product selection
 Establishment and maintenance of a secure, cost effective injection logistics system to ensure adequate supply of all necessary injection safety medical supplies and consumable.
 Strengthening and maintaining an efficient and effective logistics management information system.
 Provision of appropriate logistics for safe collection, segregation, storage and transportation equipments for sharps, injection materials and other healthcare waste.

6.0 MANAGEMENT: HUMAN RESOURCE DEVELOPMENT
6.1 Policy Issue:
 There are insufficient numbers of trained health workers; this situation is compounded by inadequate information to those in practice on the subject of safe injection practices and health care waste management
 Health workers face increased risk of hepatitis infection, as most are not fully immunized against the virus.
 Health workers do not have post HIV exposure prophylaxis in the event of accidental needle stick injuries.

6.2 POLICY OBJECTIVES:
 To review existing academic curricula of health training institutions, and incorporate harmonized injection safety and waste management issues into health worker pre-service training.
 To re-orient health care workers on harmonized injection safety and health care waste management guidelines.
 To ensure that adequate numbers of health workers are trained in providing injections and appropriately deployed to injection stations.
 To ensure that this aspect of the policy is incorporated in the professional continuing Education Development Progamme.
 To ensure that all student nurses are fully immunized against hepatitis virus.
 To ensure healthcare facilities, both public and private, have adequate supplies of post HIV exposure prophylaxis of injection safety.

6.3 Policy Strategies:
 This norms and standard are meant for those to be trained in the provision of injections and management of healthcare wastes at all health system levels for appropriate promotion of injection safety.
 Harmonize guidelines on infection control, injection waste management and other injection safety issues following the set norms and standards.
 Harmonize guidelines for immunization to include hepatitis prevention coverage in schools of nursing.
 Incorporate safety issues into pre-service training curricula of health workers.
 Incorporate safety issues into in –service training curricula for health workers at all levels.
 Re- orient practicing health workers at all relevant levels in injection safety and health care waste management through in-service training and supervision
 Train adequate numbers of health workers and deploy them appropriately at all levels of the health system including both pubic and private sectors for the provision of safe injections all health care facilities.

7.0 MONITORING AND EVALUATION
7.1 Policy Issue:
There is lack of adequate monitoring and evaluation, both in the pubic and private sectors regarding injection safety and health care waste management. Mechanisms to improve and ensure safe injection practices are limited the non-availability of appropriate data for decision- making on programmatic issues.

7.2 Policy Objective
 To ensure the development, implementation and administration of mechanisms for monitoring and evaluation encompassing both the public and private health care facilities.
 To use the monitoring and evaluation date for decision making for appropriate programmatic changes in order to improve service delivery, injection safety and health care waste management. These data based changes are also needed to ensure the safety of health workers and patients.
 To ensure the enforcement and establishment of participatory monitoring and evaluation mechanisms. These are to encompass both the public and private health care facilities.
 To establish and ensure a reliable system for detection, investigation and management of adverse events following injections.

8.0 INSTITUTIONAL FRAMEWORK
This policy will be implemented within the National Health Policy framework. In this context, the Ministry of Health will be responsible for: its dissemination, resource mobilization, coordination, supervision of implementation activities as well as monitoring and evaluation. This policy will strengthen collaboration between involved institutions and stakeholders in ensuring adherence to injection safety practices, with the Department of Public Health serving as the central coordinating unit. At the Local government level, the Primary Health department shall be responsible for ensuring implementation in the primary health care facilities.
The National Curriculum Development Committee of the Ministry of Education, in collaborating with the Ministry of Health and all relevant academic institutions, shall ensure that injection safety is included in the training curricula of health workers.
All professional and- professional health- related organizations, including practitioners in the private sector shall be responsible for ensuring that their members comply with this policy.

9.0 REGULATION
The relevant Drug Regulatory Bodies (National Agency for food and Drug Administration and control, (NAFADC) and Pharmacists Council of Nigeria, (PCN) shall ensure that health commodities and their waste management comply with national regulations and standard and also ensure compliance at all levels.
The Ministry of Environment at all levels will be responsible for advisory matters related to environmental control standards associated with the management of injection and other health care waste.

10.0 FINANCIAL IMPLICATIONS
The Ministry of Health, Development Partners, Bilateral Agencies and NGOs will finance the implementation of this policy.
The Ministry of Health and its services, as well as its development partners, including public, private and NGO sectors shall include injection safety and injection waste strategies in their budgets. These budgets should include adequate costs to support the implementation of this policy in the following areas:

 Communication and behavior change
 Waste management, including waste destruction units appropriate for each level
 Logistics, including transport costs
 Human Resource Development, and
 Monitoring and Evaluation
 Safe collection and transportation of sharps and other injection materials and disposal of same using incinerators or other environmentally acceptable means.

ENVIRONMENTAL PROTECTION
The management of injection waste shall be consistent with environmental control standards, with efforts specifically made to minimize the contamination of underground water sources and the emission of organic pollutants such as Dioxin and Furan.